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i i <br /> � <br /> ��wte�ckmv�ec@omro� ! � <br /> r���� i�i�,�. 6,��� GO � �,��� <�r:z <br /> , � � <br /> Vendor Name/Business Na e/UBI Number <br /> i <br /> f"1 u er �'('�� ��>' -�7 r ; -- ' <br /> Siate of Washington Contracior Llconso Number: <br /> I <br /> 175 � 5 �(1 '' Sf. Sr= S;'1��or'-�� 1�. l✓�� �,�7_� (�� � <br /> Ve�dor Malling Address City State Zip � <br /> �I � S 7r:.G s?Lo �fcn�-Cd <<, or.n nl�,-�l��r-+f �°��-, � , <br /> -,— <br /> Phone Email . ' <br /> ; <br /> I, the Vendor, agree to recefve the BacW�ater Prevention Device rebate check directly tor the i <br /> inst211�tion at the above referenced property address. By agreeing to recelve the rebate checic <br /> direclly, I agree to lhe iollovding: 1 <br /> 1. The Ba�icm�aler Preuention Device rebate amount will be deductetl Trom the flnal invoice ; <br /> piven to the property oa�ner for the installaliun at the properly address referenced above, if � <br /> the total cosl of the installation is greatcr than the robatc. <br /> 2. I,the Vendor, am a Washington State Iicensed contraclor. <br /> 3. Tha Clly of Gvcrett vaill send a Federal Form 1099 MISC to me,the Vendor, for 6ac1<water <br /> Prevention Devicz rebate peyments totaling more than 560D per calendar year,and will <br /> report the same payments lo the Inlemal Revenue Service. <br /> I accept ihe paymont of lhe Baclavater Prevention Device rebate from the Ciry of Everett pendinq <br /> uVprove'I of thn comploled B�c4<wNor P�cvenlion Oovlce rehatn par,kaqe by lhu City of Eve�ett : <br /> ��✓� �}tl %l7��;^_ S' a �' �f <br /> Sigoaturo of Conlractor Dale <br /> �--- - _ <br /> I <br /> ; <br /> � <br /> i <br />